1/9/2021 Week 4: Comprehensive Assessment | Completed | Shadow Health
Week 4: Comprehensive Assessment Results | Turned In
Health Assessment - GCU - December 2020, nrs-434vn
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Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Vitals
Documentation
Student Survey
Student Documentation Model Documentation
• Height: 170 cm
Vitals • Weight: 84 kg
• BMI: 29.0
BP 128/82
• Blood Glucose: 100
Pulse Ox 99%
• RR: 15
HR 78 BPM
• HR: 78
RR 15
• BP:
Temp 37.2 C
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
The patient does not give reliable report of health history as her Ms. Jones is a pleasant, 28-year-old African American single wo
mediation, symptoms and hospitalization report was different each who presents for a pre-employment physical. She is the primary
time I asked. She seemed to hesitate and have confusion with dates. source of the history. Ms. Jones offers information freely and wit
She has no primary health care provider. She leaves out information contradiction. Speech is clear and coherent. She maintains eye
about meds and diagnosis that are only uncovered by rephrasing contact throughout the interview.
question.
General Survey
The patient is healthy and able to work. She reports being happy with
past history of some stress and insomnia which have resolved. . Rx
Yaz improved symptoms; last period 6 wks ago. Takes Yaz 1x daily.
Ms. Jones is alert and oriented, seated upright on the examinatio
Allergies to penicillin (hives), cats, dust (sneeze) and asthma acts up
table, and is in no apparent distress. She is well-nourished, well-
- asthma dx at 2 years old. Reports loss of breath going up stairs. Rx
developed, and dressed appropriately with good hygiene.
albuterol 2-3 daily. Last took yesterday when she wheezed going up
stairs. Reports fatigue/ feeling full after eating sugar, glucose 90. Rx
metformin causes gas, 2x daily (850 mg). Overall healthy
hospitalizations asthma.
Support
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Reason for Visit
"I came in because I'm required to have a recent physical exam
Recent Physical needed for health insurance at new job the health insurance at my new job."
Ms. Jones reports that she recently obtained employment at Smi
Stevens, Stewart, Silver & Company. She needs to obtain a pre-
employment physical prior to initiating employment. Today she d
any acute concerns. Her last healthcare visit was 4 months ago,
History of Present Illness when she received her annual gynecological exam at Shadow H
General Clinic. Ms. Jones states that the gynecologist diagnosed
No current illness, just asthma and diabetes. Also dx of PCOS
with polycystic ovarian syndrome and prescribed oral contracept
unreported in chart.
at that visit, which she is tolerating well. She has type 2 diabetes
which she is controlling with diet, exercise, and metformin, which
just started 5 months ago. She has no medication side effects at
time. She states that she feels healthy, is taking better care of he
than in the past, and is looking forward to beginning the new job.
Medications
• Metformin, 850 mg PO BID (last use: this morning)
Albuterol inhaler for wheezing - can take up to 3x daily but last use
• Drospirenone and ethinyl estradiol PO QD (last use: this morni
was yesterday when she rain upstairs. Yaz for birth control and to
• Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yester
control PCOS. metformin 2x daily (850 mg) for type 2 diabetes. She
• Acetaminophen 500-1000 mg PO prn (headaches)
takes Advil for cramps, the OTC dose but has not taken it since her
• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6
last period over 6 weeks ago. She has taken tetracycline for acne but
weeks ago)
didnt remember the dose. No supplements.
Allergies
• Penicillin: rash
PCN, hives, has been avoiding med since she reacted. Did not • Denies food and latex allergies
remember date. She was little. Doctor told her not to take it again. • Allergic to cats and dust. When she is exposed to allergens she
Environmental allergies to dust and cats. No others reported. Dx states that she has runny nose, itchy and swollen eyes, and
asthma exacerbated by allergies and wheezing. increased asthma symptoms.
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler w
she experiences exacerbations, such as around dust or cats. He
asthma exacerbation was yesterday, which she resolved with he
Medical History inhaler. She was last hospitalized for asthma in high school. Nev
intubated. Type 2 diabetes, diagnosed at age 24. She began
She had a rt ankle injury 6 mo ago falling down stairs; hospitalized for metformin 5 months ago and initially had some gastrointestinal s
inury but took no pain medication. Dx PCOS 4 months prior and effects which have since dissipated. She monitors her blood sug
reports cramps during period. hospitalized as a kid 5x for asthma and once daily in the morning with average readings being around 90
stayed overnight. Did not remember dates. Uses an inhaler about She has a history of hypertension which normalized when she
every day. She has some pain in back but could not identify when it initiated diet and exercise. No surgeries. OB/GYN: Menarche, ag
started. Her diabtes was diagnosed at age 24 and she has a history First sexual encounter at age 18, sex with men, identifies as
of insomnia and acne (took tetracycline) but is no longer taking it. heterosexual. Never pregnant. Last menstrual period 2 weeks ag
Took no med for sleep. Problems sort of went away. Diagnosed with PCOS four months ago. For the past four month
(after initiating Yaz) cycles regular (every 4 weeks) with moderat
bleeding lasting 5 days. Has new male relationship, sexual conta
not initiated. She plans to use condoms with sexual activity. Test
negative for HIV/AIDS and STIs four months ago.
Last Pap smear 4 months ago. Last eye exam three months ago
Last dental exam five months ago. PPD (negative) ~2 years ago
Health Maintenance Immunizations: Tetanus booster was received within the past ye
influenza is not current, and human papillomavirus has been
She follows a healthy diet and avoids sugar. Remains active due to received. She reports that she believes she is up to date on child
diabetes management but not for weight loss. Wheezes on stairs. vaccines and received the meningococcal vaccine for college. S
Has smoke detectors in the home, wears seatbelt in car, and doe
not ride a bike. Uses sunscreen. Guns, having belonged to her d
are in the home, locked in parent’s room.
2/6
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